UNASSIGNED: The 2021 European Society of Cardiology (ESC) guidelines recommended a shift from a traditional hierarchical treatment for heart failure with reduced ejection fraction (HFrEF) to a four-pillar medical therapy strategy intended for near-simultaneous initiation. However, practical guidance for implementation in clinical practice is lacking. To address this, a Delphi Panel of 12 Belgian heart failure experts aimed to obtain consensus on integrating guideline-directed medical therapy (GDMT) in HFrEF patients in Belgian clinical practice, considering local specificities, including reimbursement criteria.
UNASSIGNED: A geographically representative sample of 12 Belgian cardiologists engaged in a three-round Delphi process, evolving from 20 open-ended questions to 39 statements. A qualitative analysis after the first round resulted in expert statements for the subsequent questionnaire, categorised into treatment for newly diagnosed and chronic HFrEF patients.
UNASSIGNED: The Delphi consensus revealed four key findings: (i) Agreement on initiating the four medical cornerstones within 7-14 days of HFrEF diagnosis, prioritising initiation over individual class up-titration; (ii) Lack of consensus on a fixed sequence for initiation due to patient variability and national reimbursement criteria; (iii) Emphasis on treatment adjustment based on the patient\'s clinical presentation and comorbidities; (iv) Recognition of the crucial role of regular follow-up visits, allowing optimisation of medical therapy where appropriate.
UNASSIGNED: This national Delphi consensus addresses clinical implementation of GDMT in HFrEF patients for Belgian cardiologists. The consensus highlights the importance of swift implementation of the four cornerstone medical therapies in newly diagnosed HFrEF patients, individualising treatment sequencing, and ensuring regular follow-up to optimise therapy.

BACKGROUND: Clinical associates are a health professional cadre that could be utilised in mental health task sharing in South Africa but this is training dependent. The objectives of the study were to identify the potential curricula content, training sites, and teaching modalities for undergraduate and potential postgraduate clinical associate mental health training and to identify the tasks that they should perform based on these curricula.
METHODS: We utilised the Delphi method to reach consensus on items with the panel comprising psychiatrists and family physicians. The first round questionnaire of the Delphi survey was developed based on a literature review and the results from earlier phases of the overall study. The survey was administered electronically and consisted of three rounds. Following both the first and second rounds, an updated questionnaire was constructed omitting the items on which consensus was reached. The questionnaire consisted primarily of nine-point scales with consensus based on 70% of participants rating 1,2,3 or 7,8,9.
RESULTS: There were 26 participants in the first round with this number falling to 23 in later rounds. There was strong consensus on a training attachment to a mental health clinic at a community health centre (CHC) at undergraduate (96.2%) and postgraduate level (100%). Consensus was reached on the importance of training on the management of six categories of disorders at the undergraduate level and nine categories of disorders at the postgraduate level. Clerking patients as a teaching modality reached 100% consensus at both undergraduate and postgraduate levels. PHC clinics, CHCs and district hospitals reached consensus as appropriate settings for clinical associates to provide mental health services. In addition, GP practices and secondary hospitals reached consensus for those with postgraduate training. Consensus was reached on ten of the 21 listed tasks that could be performed based on undergraduate training and 20 of the 21 tasks based on a postgraduate qualification in mental health.
CONCLUSIONS: The Delphi panel\'s recommendations provide a clear roadmap for enhancing mental health curricula for clinical associates, enabling their utilisation in mental health service provision. A future postgraduate mental health qualification for clinical associates would allow for expanded task sharing.

The goal of epilepsy treatment is seizure freedom, typically with antiseizure medication (ASM). If patients fail to attain seizure control despite two trials of appropriately chosen ASMs at adequate doses, they are classified as having drug-resistant epilepsy (DRE). Adverse events (AEs) commonly occur in people with DRE because they are typically on ⩾2 ASMs, increasing the potential for drug-drug interactions. Early emerging AEs may impact adherence, decrease quality of life, and delay achieving optimal treatment dosages. Cenobamate is an oral ASM with a long half-life which has proven to be highly effective in clinical trials. An international Delphi panel of expert epileptologists experienced in the clinical use of cenobamate and other ASMs was convened to develop consensus best practices for managing patients during and after cenobamate titration, with consideration for its known pharmacokinetic and pharmacodynamic interactions, to allow patients to reach the most appropriate cenobamate dose while limiting tolerability issues. The modified Delphi process included one open-ended questionnaire and one virtual face-to-face meeting. Participants agreed that cenobamate can be prescribed for most patients experiencing focal-onset seizures. Patients initiating cenobamate therapy should have access to healthcare professionals as needed and their treatment response should be evaluated at the 100-mg dose. Patients with intellectual disabilities may need additional support to navigate the titration period. Proactive down-titration or withdrawal of sodium channel blockers (SCBs) is recommended when concomitant ASM regimens include ⩾2 SCBs. When applicable, maintaining a concomitant clobazam dose at ~5-10 mg may be beneficial. Patients taking oral contraceptives, newer oral anticoagulants, or HIV antiretroviral medications should be monitored for potential interactions. Because clinical evidence informing treatment decisions is limited, guidance regarding dose adjustments of non-ASM drugs was not developed beyond specific recommendations presented in the Summary of Product Characteristics.

Introduction: Incidental pulmonary nodules (IPN) are common radiologic findings, yet management of IPNs is inconsistent across Canada. This study aims to improve IPN management based on multidisciplinary expert consensus and provides recommendations to overcome patient and system-level barriers. Methods: A modified Delphi consensus technique was conducted. Multidisciplinary experts with extensive experience in lung nodule management in Canada were recruited to participate in the panel. A survey was administered in 3 rounds, using a 5-point Likert scale to determine the level of agreement (1 = extremely agree, 5 = extremely disagree). Results: Eleven experts agreed to participate in the panel; 10 completed all 3 rounds. Consensus was achieved for 183/217 (84.3%) statements. Panellists agreed that radiology reports should include a standardized summary of findings and follow-up recommendations for all nodule sizes (ie, <6, 6-8, and >8 mm). There was strong consensus regarding the importance of an automated system for patient follow-up and that leadership support for organizational change at the administrative level is of utmost importance in improving IPN management. There was no consensus on the need for standardized national referral pathways, development of new guidelines, or establishing a uniform picture archiving and communication system. Conclusion: Canadian IPN experts agree that improved IPN management should include standardized radiology reporting of IPNs, standardized and automated follow-up of patients with IPNs, guideline adherence and implementation, and leadership support for organizational change. Future research should focus on the implementation and long-term effectiveness of these recommendations in clinical practice.

Aim: Obtain clinical consensus on factors impacting first-line prescribing for transplant-ineligible (TIE) patients with newly diagnosed multiple myeloma (NDMM). Materials & methods: A double-blinded, modified Delphi panel was employed. USA-based hematologists/oncologists who treat TIE patients with NDMM were selected as expert panelists. Results: Consensus was reached that patient frailty, performance status, comorbidities, treatment efficacy, and adverse event profile affect first-line prescribing. All panelists agreed it is important to use the most efficacious treatment first; 88% of panelists considered daratumumab-containing regimens the most efficacious. Panelists agreed treatment should be continued until progression while benefits outweigh risk. Conclusion: Findings reinforce the importance of using the most efficacious regimen upfront for TIE NDMM, and nearly all panelists considered daratumumab-containing regimens the most efficacious treatment.
The purpose of this study was to determine the latest clinician preferences and opinions on factors affecting initial treatment selection for people recently diagnosed with multiple myeloma and unable to receive a bone marrow transplant, and to understand challenges with current treatments used in clinical practice. A panel of doctors with an average of two decades of experience treating blood disorders and cancers were recruited as expert panelists. Experts discussed treatment options by completing two rounds of surveys on treatment and one round of discussion. All experts agreed that the most effective treatment should be used first. Most experts considered treatment containing the drug daratumumab to be the most effective. Experts agreed that treatment should be continued until the cancer worsens if the treatment offers more benefits than side effects.

OBJECTIVE: A recent applicability study highlighted the need for the existing checklist for reporting research using a simulated patient methodology (CRiSP) to be clearer and user-friendly. The aim of this study was to update the checklist to address these concerns.
METHODS: A fourth round of the Delphi consensus study, used in the original checklist development work, was conducted. Previous participants, who had expertise in SP methodology, were invited to complete a questionnaire including a list of 13 checklist items developed in the previous study and revised following applicability testing. Closed questions were analysed for frequency. Consensus was predefined as >80% agreement. All items were discussed in a roundtable meeting and further modified as necessary. Responses to open questions were content analysed.
RESULTS: Twenty-one authors participated. There was a statistical consensus in 12 out of 13 modified checklist items.
CONCLUSIONS: A final reporting checklist for studies in health research using SP methodology has been developed using a consensus approach. Further refinements may be needed to increase the generalizability of the checklist in different contexts.

BACKGROUND: Existing approaches in cancer survivorship care delivery have proven to be insufficient to engage primary care. This study aimed to identify stakeholder-informed priorities to improve primary care engagement in breast cancer survivorship care.
METHODS: Experts in U.S. cancer survivorship care delivery were invited to participate in a 4-round online Delphi panel to identify and evaluate priorities for defining and fostering primary care\'s engagement in breast cancer survivorship. Panelists were asked to identify and then assess (ratings of 1-9) the importance and feasibility of priority items to support primary care engagement in survivorship. Panelists were asked to review the group results and reevaluate the importance and feasibility of each item, aiming to reach consensus.
RESULTS: Respondent panelists (n = 23, response rate 57.5%) identified 31 priority items to support survivorship care. Panelists consistently rated three items most important (scored 9) but with uncertain feasibility (scored 5-6). These items emphasized the need to foster connections and improve communication between primary care and oncology. Panelists reached consensus on four items evaluated as important and feasible: (1) educating patients on survivorship, (2) enabling screening reminders and monitoring alerts in the electronic medical record, (3) identifying patient resources for clinicians to recommend, and (4) distributing accessible reference guides of common breast cancer drugs.
CONCLUSIONS: Role clarity and communication between oncology and primary care were rated as most important; however, uncertainty about feasibility remains. These findings indicate that cross-disciplinary capacity building to address feasibility issues may be needed to make the most important priority items actionable in primary care.

OBJECTIVE: The U.S. Food & Drug Administration has identified physical functioning (PF) as a core patient-reported outcome (PRO) in cancer clinical trials. The purpose of this study was to identify PF PRO measures (PROMs) in adult cancer populations and classify the PROMs by content covered (facets of PF) in each measure.
METHODS: As part of the Patient Reports of Physical Functioning Study (PROPS) research program, we conducted a targeted literature review to identify PROMs that could be used in clinical trials to evaluate PF from the patient perspective. Next, we convened an advisory panel to conduct a modified, reactive, Delphi study to reach consensus on which PF facets are assessed by PROMs identified in the review. The panel engaged in a \"card sort\" activity to classify PROM items by PF facets. Consensus was reached when 80% of panel members agreed that at least one facet was being measured by each PROM item.
RESULTS: The literature review identified 13 PROMs that met inclusion criteria. Eight facets of PF were identified for classification in the Delphi study: ability, completion, difficulty, limitation, quality, frequency, bother, and satisfaction. Through two rounds, the panel documented and classified conceptual approaches for each PRO item presented. The most prevalent PF facets were ability, difficulty, and limitation.
CONCLUSIONS: Classifying PF PROMs by PF facets will promote more consistent communication regarding the aspects of PF represented in each PROM, helping researchers prioritize measures for inclusion in cancer clinical trials.

Limited guidance exists to support investigators in the choice, adaptation, validation and use of implementation measures for global mental health implementation research. Our objectives were to develop consensus on best practices for implementation measurement and identify strengths and opportunities in current practice. We convened seven expert panelists. Participants rated approaches to measure adaptation and validation according to appropriateness and feasibility. Follow-up interviews were conducted and a group discussion was held. We then surveyed investigators who have used quantitative implementation measures in global mental health implementation research. Participants described their use of implementation measures, including approaches to adaptation and validation, alongside challenges and opportunities. Panelists agreed that investigators could rely on evidence of a measure\'s validity, reliability and dimensionality from similar contexts. Panelists did not reach consensus on whether to establish the pragmatic qualities of measures in novel settings. Survey respondents (n = 28) most commonly reported using the Consolidated Framework for Implementation Research Inner Setting Measures (n = 9) and the Program Assessment Sustainability Tool (n = 5). All reported adapting measures to their settings; only two reported validating their measures. These results will support guidance for implementation measurement in support of mental health services in diverse global settings.

Demodex blepharitis does not have agreed standardized guidelines. The aim of this study was to classify signs and symptoms and to develop appropriate management strategies for Demodex blepharitis from a consensus of expert advice.
METHODS: A total of 11 anterior segment experts (ophthalmologists, optometrists and a contact lens optician) working in the United Kingdom participated in a modified 2-round Delphi panel. A mixed-methods approach was adopted and a survey questionnaire for round 1 was formulated, constructed from information in the available literature. Based on panel responses from round 1, feedback was provided and a round 2 questionnaire was formulated. More than two-thirds majority (72%) was used for consensus building.
RESULTS: Based on the clinical presentation of signs and symptoms along with associated conditions and risk factors, a diagnostic algorithm was proposed for the clinical investigation of Demodex blepharitis. A treatment algorithm was also proposed with first-line and second-line treatment recommendations for Demodex blepharitis.
CONCLUSIONS: The recommendation from this study provides the first effort in formulating clinical diagnostic algorithm and management guidelines for Demodex blepharitis. The guidelines include appropriate magnification on the slit lamp, associated signs, symptoms, risk factors and suggested management options. These guidelines can be used in a routine eyecare setting to encourage eyecare practitioners in tailoring the investigation and management of Demodex blepharitis.